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  • John Kingston

The investigation model of last resort?

Investigators do the investigations that they can live with; that tends not to be talked about much. Instead, writers and trainers focus on the technical parts. In doing so, they imply that an investigator’s job is to find a uniquely correct explanation of an accident. This can be true only in part. One can be objective about the ‘what happened and how’, but these facts do not speak for themselves. Instead, learning takes place in an environment of contrasting, sometimes clashing, explanations. The agreed facts of ‘what’ and ‘how’ reveal many different facets of ‘who’ and ‘why’. But if the investigator’s role is not to be a superknower, there to judge the rightness of everyone’s positions, what else might it be? According to Charles Tilly, explanations do relational work. Even technical explanations do more than adjust the calculated basis for a design. By finding causes, an investigation creates explanations that can be used to create, confirm, negotiate or repair relationships post-accident. Only a few times in my career have I seen leaders opt for this ‘relational’ model of investigation. The accidents had taken their organisations to a tipping point, with stakeholder confidence stretched too far to spring back. But when I say ‘leaders’, actually the whole community has to authorise this form of learning. They lend the investigator some of their power, and also take a more active role themselves. This seems to be the learning model of last resort; a pity, because sometimes it is too late to learn.

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